Time for a major re-think
– Written by Mark A. Tully and Ruth F. Hunter, United Kingdom
IMPORTANCE OF PHYSICAL ACTIVITY FOR HEALTH
Non-communicable diseases such as heart disease and diabetes place a huge burden on the healthcare system. The rising level of physical inactivity is recognised as one of the major threats to public health. It has been estimated that in 2008, physical inactivity caused 9% of premature mortality and 5.3 million deaths worldwide, making it the fourth leading cause of death globally1. It was also estimated that between 6 and 10% of all deaths from non-communicable diseases globally are caused by physical inactivity, with the burden of these diseases continuing to increase rapidly in low- and middle-income countries. Physical activity accounts for a similar number of global deaths as smoking, but there have been considerably fewer organised efforts to combat it1.
Regular physical activity has been found to contribute to the prevention and management of over 20 chronic health conditions, including heart disease, stroke, diabetes, cancer, obesity and musculoskeletal conditions, as well as mental-health problems2. In addition to benefits to physical health, regular physical activity contributes to the prevention of falls and cognitive function in older adults and academic achievement in young people.
It has been estimated that physical inactivity costs the UK National Health Service £1.06 billion per year through its direct contribution to chronic non-communicable diseases2. In addition to the health costs, physical inactivity has been estimated to have wider societal economic costs of £5.5 billion per year from work absence due to sickness and £1 billion per year from the premature deaths of people of working age. Moreover, promoting physically active modes of travel such as walking and cycling to work and school can contribute to reducing harmful air pollution and greenhouse gas emissions. However, there has been minimal government investment relative to other health behaviours into researching effective ways to encourage physical activity.
LEVELS OF PHYSICAL ACTIVITY
Every adult should try to be physically active daily, aiming to accumulate at least 150 minutes of moderate-intensity activity per week2. A concerning global trend of rapidly decreasing physical activity levels has led to some referring to the current situation as a ‘physical inactivity pandemic’3.
Despite the numerous benefits of physical activity, levels remain low in Northern Ireland, where two-thirds of adults do not participate in a sufficient amount of physical activity to confer a health benefit and one-third of the population participates in no physical activity at all4. This is similar to the level of physical activity in the rest of the UK and worldwide. Levels of physical activity are lower in older people, people with a disability or long-term health conditions and people with a high BMI. The majority (68%) of moderate-intensity activity is accumulated at work or at home, while sport (18%) and active travel (14%) play a smaller role. Levels of physical activity are lower in individuals from lower socio-economic groups, who accumulate a greater proportion of their physical activity from work and less from active travel and recreation.
REASONS FOR LOW PHYSICAL ACTIVITY LEVELS
Research has demonstrated that there are three main levels of influence on physical activity: individual, social and environmental. Individual factors include attitudes to physical activity, social and health inequalities, beliefs about the benefits of physical activity and individuals’ beliefs about their ability to change their lifestyle.
It is important to note that people rarely view physical activity as a standalone event. Physical activity is viewed as part of a complex pattern of behaviours that is not easily disentangled from other activities of daily living. This is at odds with strategies favoured by policy makers, which often focus on promoting a single type of activity such as sport or active travel. Our research has demonstrated that to tackle the low levels of societal physical activity, society must move beyond approaches that focus on individuals and consider the social and environmental contexts in which physical activity occurs5.
More recently, there has been focus on the effects of the built environment on physical activity. Considerable evidence is mounting on the association between physical activity and the built environment in which an individual lives. Features of the built environment associated with increased physical activities such as walking and cycling include greater land-use mix, street connectivity, presence and conditions of sidewalks and street lighting. Individuals’ perceptions of the support offered by their local neighbourhood for physical activity are also associated with levels of activity. Such perceptions include perceived safety, residential density, aesthetics and proximity of facilities for walking and cycling.
INTERVENTIONS: TIME FOR A RE-THINK
Heath et al6 summarised the findings of previous reviews, to identify effective, promising or emerging interventions from around the world. They identified that previous initiatives have had only modest effects and maintained changes in physical activity behaviour are difficult to achieve. Therefore, it is necessary that there be a major re-think in approaches to public-health interventions. Given the limited effect of previous efforts, more innovative approaches need to be developed to halt the global rise in physical inactivity.
Previous government-led efforts in the UK to address physical inactivity have largely focused on health-promotion efforts within specific settings, for example, healthcare settings establishing exercise-referral schemes. These interventions have primarily targeted the individual-level factors associated with inactive lifestyles such as education.
Recent guidelines from the UK National Institute of Health and Care Excellence (NICE) have recommended that interventions should include techniques that have been demonstrated to be effective at changing behaviour, including setting goals, providing feedback, monitoring progress and providing social support7. There are several examples of successful interventions in Northern Ireland that have used pedometers to help people set goals. These interventions led to significant improvements in health and well-being in a variety of populations8. However, they have demonstrated a limited ability to sustain behaviours beyond the timeframe of the intervention. This may be because they omit to intervene in either the social or physical environmental context in which the behaviour occurs.
INCENTIVISING HEALTH-BEHAVIOUR CHANGE
‘Nudge’ policies and the use of incentives have been advocated by the UK government to encourage the adoption of healthy lifestyles9. Although this idea has captured the imagination of policy makers, others are concerned that without specific evidence, such policies may be implemented too widely to the detriment of alternative approaches10. An increasing number of behavioural economists are beginning to research the role of incentives in encouraging healthy behaviours with promising results in changing some behaviour, for example, smoking and substance abuse. However, there is little evidence for the efficacy of this approach in other health behaviours. Some financial and non-financial incentives have been found to increase levels of physical activity, at least in the short term and mainly with respect to structured exercise programmes rather than free-living physical activity11.
Research conducted in Northern Ireland aims to address such gaps in the evidence. For example, research is examining factors such as how individual interventions interact with environmental factors to encourage people to walk, how to make walking habitual and which elucidating factors influence long-term behavioural change. The Physical Activity Loyalty (PAL) scheme is a multi-component intervention based on concepts similar to those that underpin a high-street loyalty card aimed at encouraging repeated behaviour (i.e. loyalty). Components include the provision of points and rewards (financial incentives) contingent on the targeted behaviour (physical activity) and the provision of feedback on the targeted behaviour, prompting and offering messages to encourage the targeted behaviour through a tailored website12.
Using a loyalty card to collect points and earn rewards (Figure 1), participants (n=199) in the PAL Incentive Group monitored their physical activity levels and received financial incentives (retail vouchers) for minutes of physical activity completed over the course of a 12-week intervention period. Participants (n=207) in the comparison group (no incentive group) used their loyalty card to self-monitor their physical activity levels but were not able to earn points or obtain incentives. Quality of life and absenteeism were assessed at baseline and 6 months follow-up. Results from a cost-effectiveness analysis demonstrated that the PAL scheme is potentially cost-effective from both a healthcare and employer perspective. The PAL scheme is based on a sustainable ‘business model’ that should become more cost-effective as it is delivered to more participants and can be adapted to suit other health behaviours and settings. This comes at a time when the governments of the UK and the USA are encouraging business involvement in tackling public-health challenges13.
For financial-incentive schemes to be worthwhile in the long term and implemented on a large scale, they must be based on a sustainable model. Previous studies have used significant cash payments (up to US$750), which were found not to be sustainable for the long term. The ready ‘buy-in’ of the retail partners in our study suggests that a sustainable model is achievable. Such schemes could provide a ‘win-win’ situation for both public health and businesses by offering modest financial incentives such as retail vouchers in return for an increased number of customers for local retailers; this idea is aligned with the precepts of the Public Health Responsibility Deal9.
Public-health specialists have long recognised that berating individuals to change their behaviour seldom works and have adopted a broader approach that recognises the role of supportive environments that can make healthy choices easier. However, physical activity is a complex behaviour that modern built and social environments often discourage. The government can facilitate population-level behavioural change by providing supportive environments. The potential of the built environment to influence population levels of physical activity has been recognised by the World Health Organisation and the UK Foresight report14.
THE ROLE OF THE BUILT ENVIRONMENT
The UK Foresight report14 highlights the need for evidence of the effectiveness of environmental interventions to help to sustain behavioural changes. There have been large government-commissioned reviews of approaches for promoting and creating environments that encourage and support physical activity in the UK. These reviews recognise that past policy and practice has prioritised sedentary modes of transport, even if unintentionally. Based on systematic reviews of policy, transport, urban planning and architecture, NICE identified a number of recommendations for practice, including changes to planning, transport and design, to improve accessibility to opportunities to incorporate physical activity into activities of daily living. NICE also recommended that research councils and funding bodies should prioritise funding to evaluate the effectiveness of environmental interventions on physical activity; this has led to an upsurge of research activity in this area. However, there is a lack of evidence on the effect of urban-regeneration projects on public health, particularly the nature and degree to which urban regeneration affects health-related behavioural change.
Research currently being conducted in Northern Ireland is seeking to address this knowledge gap. The Connswater Community Greenway (http://www.communitygreenway.co.uk) in Belfast is a major urban-regeneration project involving the development of a 9 km linear park, including the provision of new cycle paths and walkways (Figure 2). In addition to the environmental improvements, this complex intervention involves a number of programmes to promote physical activity in the regenerated area. The Connswater Community Greenway project provides a significant opportunity to achieve long-term population-level behavioural change and affords a unique opportunity to investigate the public-health effects of urban regeneration. Urban regeneration may be conceptualised meaningfully as a complex intervention comprising multiple components with the potential, individually and interactively, to affect the behaviour of a diverse population.
The Physical Activity and the Regeneration of Connswater (PARC) Study15 is a natural experiment investigating the public-health effect – including physical activity behaviour, health and mental well-being – of the Greenway on the local population. The study includes the following key components:
a quasi-experimental before-and-after survey of the Greenway population (repeated cross-sectional design) in tandem with data (for comparison) from a parallel survey conducted throughout Northern Ireland
an assessment of changes in the local built environment and of walkability using geographic information systems
semi-structured interviews with a purposive sample of survey respondents and a range of community stakeholders conducted before and after the regeneration project
a cost-effectiveness analysis.
This study will add to the greatly needed evidence base on the effect of urban regeneration on public health.
Using modelling techniques, the effect of programmes or policies on population health or population subgroups can be assessed from the outset. Using the macro-simulation Prevent model, the potential health effects and cost-effectiveness of the Connswater Community Greenway were estimated16. The study modelled the potential effects of the Connswater Community Greenway on the burden of cardiovascular disease (namely, ischaemic heart disease), type 2 diabetes mellitus, as well as stroke and colon and breast cancer by the year 2050 if feasible increases in physical activity are achieved. Results demonstrated that if 10% of people classified as ‘inactive’ (i.e. perform fewer than 150 minutes of moderate activity per week) became ‘active’, 886 incident cases (1.2%) and 75 deaths (0.9%) could be prevented with an incremental cost-effectiveness ratio (ICER) of £4469/disability-adjusted life year. For effectiveness estimates as low as 2%, the intervention would remain cost-effective (£18,411/disability-adjusted life year). Small gains in average life expectancy and disability-adjusted life expectancy could be achieved and the Greenway population would benefit from 46 fewer years lived with disability. Therefore, the Greenway could be cost-effective in improving physical activity levels. Although the direct health gains are predicted to be small for any individual, summed over an entire population, they are substantial. In addition, the Greenway is likely to have benefits beyond health, including reductions in carbon emissions, improvements in safety and less crime.
KNOWLEDGE AND AWARENESS OF HEALTH RECOMMENDATIONS
Knowledge and awareness of how much physical activity individuals should undertake to achieve health benefits is an important precursor to behavioural change. An understanding of the socio-demographic characteristics of those who are unaware of the guidelines can help develop better targeted health-promotion interventions. Results from our study demonstrated that despite efforts for public-health promotion, there is a considerable lack of knowledge of UK physical activity guidelines in Northern Ireland, with only 8.4% of adults able to identify correctly the recommended minimum amount of physical activity17. Further, our results demonstrated that males with a lower level of education (OR 5.91; 95% CI 1.67, 20.94), living in more deprived areas (OR 4.80; 95% CI 1.87, 12.30), doing no physical activity (OR 2.74; 95% CI 1.31, 5.76) and with a low income (OR 2.36; 95% CI 1.63, 3.41) were more likely to be unaware of the UK guidelines. In addition, younger females (OR 1.03; 95% CI 1.02, 1.05) who reported poor health (OR 2.71; 95% CI 1.61, 4.58) were more likely to be unaware of the UK guidelines. The need to reach large target populations at a low cost with the aim of influencing awareness and knowledge and changing modifiable health behaviours is essential for achieving effective public-health promotion.
THE ROLE OF THE SOCIAL ENVIRONMENT
In some respects, the role of the social environment (e.g. social capital, social support) is significantly under-utilised in promoting physical activity behavioural change18. Despite social support being identified as an important correlate for physical activity behavioural change, few studies measure any features of the social environment or utilise aspects of the social environment in interventions. The social environment is inherent in physical activity programmes (e.g. walking groups, dog walking) in which people can meet, ‘get out and about’5, and be active. Further, a previous review has suggested that multi-component, group-based interventions were most effective in increasing physical activity in socio-economically disadvantaged communities19.
Physical inactivity is a major public-health concern with implications for our health, society and economy. Therefore, the public-health dividend of increasing physical activity in the population is substantial. Previous initiatives have had only modest effects, with maintained changes in physical activity behaviour proving difficult to achieve. Thus, a major re-think in approaches to changing levels of physical activity is required. The government can facilitate population-level behavioural change by providing supportive physical and social environments. Therefore, there is a need to move beyond individual-level approaches towards broader population interventions that provide such supportive environments. To facilitate this shift, physical activity should be integrated into cross-departmental policies. Without a concerted effort to target physical activity directly in all relevant policies and actions, physical inactivity and its consequences will remain.
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Mark A. Tully Ph.D.
Lecturer in Physical Activity and Public Health
Ruth F. Hunter Ph.D.
Lecturer in Physical Activity and Public Health
UKCRC Centre of Excellence for Public Health (NI)
Centre for Public Health
School of Medicine, Dentistry and Biomedical Sciences
Queen’s University Belfast
Belfast, United Kingdom
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